2022 Canadian Urological Association best practice report: Vasectomy

Question 1

Figure 1. Proposed algorithm for post-vasectomy testing protocol.

Question 2

What is the primary purpose of a vasectomy?

Answer 2

What is the primary purpose of a vasectomy?

Question 3

What are the potential complications associated with vasectomy?

Answer 3

Vasectomy, although a simple elective procedure, can have potential minor and major complications.

Question 4

What is the early failure rate of vasectomy?

Answer 4

The early failure rate (presence of motile sperm in the ejaculate at 3–6 months post-vasectomy) is between 0.2–5%.

Question 5

How does the late failure rate of vasectomy compare to the early failure rate?

Answer 5

The late failure rate is much lower, ranging between 0.04–0.08%. (4-8 en 10.000)

Question 6

Which vasectomy technique is associated with a lower risk of early postoperative complications?

Answer 6

The no-scalpel vasectomy technique.

Question 7

How can the risk of contraceptive failure be reduced in vasectomy?

Answer 7

By using cautery or fascial interposition.

Question 8

Why is careful assessment of the post-vasectomy ejaculate imperative?

Answer 8

To check for the presence of sperm, which can indicate failure.

Question 9

What potential legal issue can arise if adequate information and counselling aren’t provided to patients about vasectomy?

Answer 9

Failure to provide and document sufficient information and counselling can lead to litigation.

Question 10

What is the main focus of the 2022 Canadian Urological Association guideline on Vasectomy?

Answer 10

The management of men presenting for vasectomy, covering preoperative counselling, vasectomy efficacy and complications, technical aspects, post-vasectomy semen testing, and interpretation-communication of post-vasectomy semen results.

Question 11

What is the ultimate objective of the guideline?

Answer 11

To help standardize the treatment of men presenting for vasectomy through evidence-based consensus.

Question 12

What should be described during the initial consultation for a vasectomy?

Answer 12

The procedure.

Question 13

List the early complications of a vasectomy that men must be informed about.

Answer 13

List the early complications of a vasectomy that men must be informed about.

Question 14

List the early complications of a vasectomy that men must be informed about.

Answer 14

Infection (0.2–1.5%), bleeding or hematoma (4–20%), and primary (early) surgical failure (0.2–5%).

Question 15

When might motile sperm be seen in the ejaculate post-vasectomy?

Answer 15

3–6 months post-vasectomy.

Question 16

What are the late complications of vasectomy?

Answer 16

Chronic scrotal pain (1–14%) and delayed vasectomy failure after azoospermia at four months (0.05–1%).

Question 17

How often might complications like bleeding and testicular pain necessitate surgical intervention?

Answer 17

Infrequently (<0.1%).

Question 18

How should information about vasectomy complications be provided to the patient?

Answer 18

Verbally and through an information pamphlet.

Question 19

How should a vasectomy be viewed in terms of contraception?

Answer 19

As a permanent form of contraception with a high probability of reversibility.

Question 20

Which alternatives can be discussed if patients are concerned about the permanent nature of vasectomy?

Answer 20

Preoperative sperm banking, postoperative vasectomy reversal, and sperm retrieval for in vitro fertilization.

Question 21

Is there a clear association between vasectomy and prostate cancer?

Answer 21

No.

Question 22

Which complications need not be discussed unless the patient inquires?

Answer 22

Vascular disease, hypertension, testicular cancer.

Question 23

Why must couples continue to use other contraceptive measures shortly after a vasectomy?

Answer 23

Due to the potential for early re-canalization, technical failure, and the rate of primary (early) surgical failure (0.2–5%).

Question 24

What action is recommended if motile spermatozoa are present in the ejaculate six months after the procedure?

Answer 24

A re-do vasectomy.

Question 25

What is the suggested approach if patients are ready to undergo a vasectomy at the end of the initial consultation?

Answer 25

Vasectomy may be performed shortly after the initial consultation unless there are valid medical reasons to wait.

Question 26

How common is it for men below the age of 25 in the U.S. to choose vasectomy as a form of contraception?

Answer 26

Rare.

Question 27

What is the likelihood of men in their 20s seeking vasectomy reversal if they underwent vasectomy in their 20s?

Answer 27

12.5 times greater.

Question 28

What is the estimated prevalence of varicoceles in the general male population?

Answer 28

15%.

Question 29

What special considerations should be made when performing vasectomy in men with a clinical varicocele or with prior varicocelectomy?

Answer 29

Carefully isolate the vas deferens and completely exclude the associated deferential arteries and veins to avoid potential injury.

Question 30

Evolution of vasectomy techniques

Answer 30

Over the years, the technique of vasectomy has seen significant modifications. This includes changes in equipment, materials, and methods of anesthesia.

Question 31

Importance of continuing medical education for surgeons performing vasectomies

Answer 31

Surgeons should obtain regular continuing medical education on vasectomy. This includes updates on surgical techniques and staying informed on new studies in the latest peer-reviewed journals and clinical guidelines.

Question 32

Preferred anesthesia for vasectomy procedures

Answer 32

Local anesthesia is typically sufficient for most vasectomy patients. However, anxious patients or those with complicating factors might need sedation or a general anesthetic.

Question 33

What are some complicating factors that may require a patient to receive sedation or general anesthesia for a vasectomy?

Answer 33

Previous orchidopexy or other scrotal surgeries.

Question 34

Controversy surrounding the use of topical anesthetic before injection of local anesthetic for vasectomy

Answer 34

There is controversy regarding the benefit of using topical anesthetic prior to injecting a local anesthetic for vasectomy procedures.

Question 35

Recommended needle gauge for vasectomy local anesthesia

Answer 35

A small, 27–32-gauge needle is thought to be beneficial for local anesthesia during vasectomy.

Question 36

Effectiveness of pneumatic injectors in vasectomy procedures

Answer 36

Pneumatic injectors have not shown a clear benefit for vasectomy procedures. However, they might be suitable for patients with a needle phobia.

Question 37

Use of buffered xylocaine in vasectomy patients

Answer 37

The use of buffered xylocaine has not been studied in vasectomy patients.

Question 38

What are the two most common surgical techniques for accessing the vas during vasectomy?

Answer 38

Traditional incisional method
No-scalpel vasectomy (NSV) technique

Question 39

Differentiate between the conventional incisional technique and the NSV technique.

Answer 39

Conventional incisional technique uses a scalpel to make one or two incisions in the scrotal skin to access the vas deferens. NSV technique uses a sharp, forceps-like instrument to puncture the skin to access the vas deferens.

Question 40

Conventional incisional technique uses a scalpel to make one or two incisions in the scrotal skin to access the vas deferens. NSV technique uses a sharp, forceps-like instrument to puncture the skin to access the vas deferens.

Question 41

What advantages does the NSV approach have over the standard incision technique based on the Cochrane review?

Answer 41

What advantages does the NSV approach have over the standard incision technique based on the Cochrane review?

Question 42

What advantages does the NSV approach have over the standard incision technique based on the Cochrane review?

Answer 42

Lower risk of postoperative hematoma
Less pain during surgery
Reduced postoperative scrotal pain
Fewer wound infections
Faster procedure

Question 43

Provide the odds ratios (OR) and 95% confidence intervals (CI) for the postoperative hematoma, pain during surgery, postoperative scrotal pain, and wound infections in NSV compared to the standard incision technique.

Answer 43

Provide the odds ratios (OR) and 95% confidence intervals (CI) for the postoperative hematoma, pain during surgery, postoperative scrotal pain, and wound infections in NSV compared to the standard incision technique.

Question 44

Is there a significant difference in the effectiveness between NSV and the conventional scalpel technique?

Answer 44

Is there a significant difference in the effectiveness between NSV and the conventional scalpel technique?

Question 45

What is the recommendation regarding NSV based on the risk of postoperative complications?

Answer 45

NSV should be performed because it is associated with a significantly lower risk of postoperative complications such as hematoma, pain, and infection than conventional vasectomy (Grade A–B).

Question 46

Vasectomy Technique: Importance of Fascial Interposition

Answer 46

Fascial interposition during vasectomy results in a significantly higher rate of azoospermia at three months than simple ligation and excision without fascial interposition. (OR 0.42, 95% CI 0.26–0.70).

Question 47

Potential Complications of Fascial Interposition in Vasectomy

Answer 47

Fascial interposition may increase the complication rate of vasectomy.

Question 48

Mucosal Cautery vs. Fascial Interposition: Risk of Vasectomy Failure

Answer 48

Cautery of the vas is associated with a lower risk of failure (defined as >100,000 sperm in the ejaculate) than fascial interposition (1% vs. 4.9%, OR 4.8, 95% CI 1.6–14.3).

Question 49

Recommendation for Vasectomy Technique

Answer 49

Mucosal cautery and/or fascial interposition (with vas ligation and excision) should be performed during vasectomy. These techniques are associated with the lowest failure rates (Grade B). However, surgeons can use their preferred occlusion technique if they achieve consistently low vasectomy failure rates.

Question 50

After a vasectomy, what care instructions should be given to patients regarding their wound and scrotum?

Answer 50

Men should be instructed about proper wound and scrotal care and informed about short-term physical limitations.

Question 51

How should men be instructed to collect the semen sample post-vasectomy?

Answer 51

Men should be told to collect the semen sample with completeness, using a specific type of container, and to submit it to the laboratory within 30–60 minutes after producing the sample.

Question 52

Men should be told to collect the semen sample with completeness, using a specific type of container, and to submit it to the laboratory within 30–60 minutes after producing the sample.

Question 53

What is the recommended abstinence period before collecting a semen sample after vasectomy?

Answer 53

Semen samples should be collected after an abstinence period of two or more days and no more than seven days.

Question 54

Semen samples should be collected after an abstinence period of two or more days and no more than seven days.

Question 55

How should the semen sample be maintained before delivery to the laboratory?

Answer 55

The semen sample should be maintained at body temperature before delivery to the laboratory.

Question 56

What information should be provided to men regarding post-vasectomy semen analysis labs?

Answer 56

Men should be given a list of local laboratories that perform proper post-vasectomy semen analysis.

Question 57

Men should be given a list of local laboratories that perform proper post-vasectomy semen analysis.

Question 58

Until when should men continue to use other contraceptive measures after a vasectomy?

Answer 58

Men must continue to use other contraceptive measures until post-vasectomy semen testing has confirmed the absence of motile sperm.

Question 59

Early failure rate of vasectomy range and its determinants.

Answer 59

0.2–5%. Linked to surgeon experience and technique.

Question 60

Plausible explanations for early vasectomy failure.

Answer 60

Technical failure (e.g., missed vas deferens) and early re-canalization of the vas deferens.

Question 61

Define “late vasectomy failure” and its reported range.

Answer 61

Presence of motile spermatozoa in the ejaculate after documented azoospermia in two post-vasectomy semen analyses. Range: 0.04–0.08% (approximately 1/2000 cases).

Question 62

Reappearance rate of sperm (often immotile) after documented azoospermia three months post-vasectomy.

Answer 62

Nearly 10% of ejaculates from men undergoing semen assessment prior to vasectomy reversal.

Question 63

Significance of reappearance or persistence of immotile sperm years after vasectomy.

Answer 63

It’s unlikely to be of clinical significance as it hasn’t been associated with documented pregnancies.

Question 64

What should the post-vasectomy semen analysis be performed on?

Answer 64

Fresh (unprocessed) semen and on the centrifuged semen.

Question 65

Why is the centrifuged semen analysis done post-vasectomy?

Answer 65

To confirm the absence of low numbers of motile sperm.

Question 66

What should the laboratory provide an estimation of during a post-vasectomy semen analysis?

Answer 66

Sperm concentration or numbers of spermatozoa observed per high power field (×400 magnification).

Question 67

What percentage of men fail to submit even a single sample for post-vasectomy semen testing?

Answer 67

Up to 30%.

Question 68

When is a single semen analysis deemed sufficient to consider the vasectomy effective?

Answer 68

When it shows azoospermia or rare non-motile sperm (<100,000 non-motile sperm/ml), assuming the analysis is done by an experienced, reputable lab.

Question 69

What is the risk of conversion from azoospermia or rare non-motile sperm to greater numbers of sperm, based on Alderman’s study of 5233 vasectomies?

Answer 69

Very rare, approximately 0.1% of cases.

Question 70

What is the predictive value of a single semen analysis with rare non-motile sperm for vasectomy success, as estimated by Barone et al.?

Answer 70

99.7%.

Question 71

When should a second semen analysis be requested post-vasectomy?

Answer 71

In men with greater numbers of non-motile sperm (>100,000 non-motile sperm/ml) and/or any number of motile sperm on the first semen analysis.

Question 72

What might be a potential advantage of clinicians requesting two semen samples at the onset?

Answer 72

It may reduce the number of post-vasectomy counselling sessions (e.g., phone calls or office visits).

Question 73

What might be a potential drawback of clinicians requesting two semen samples at the onset?

Answer 73

It may decrease the overall compliance.

Question 74

What is the recommendation regarding the number of semen samples post-vasectomy?

Answer 74

A single semen sample showing azoospermia or rare non-motile sperm (<100,000 non-motile sperm/ml) is sufficient to deem the vasectomy effective. A second analysis should be requested in certain conditions, like greater number of non-motile sperm or presence of motile sperm in the first analysis (Grade C).

Question 75

What is the primary reason for the debate regarding the timing of post-vasectomy semen testing?

Answer 75

The difficulty in establishing a set time point for semen testing largely comes from the variable success of the vasectomy occlusion techniques.

Question 76

Which vasectomy occlusion technique takes longer to achieve azoospermia, and which ones achieve it faster?

Answer 76

Azoospermia is achieved much later with the ligation (and excision) compared to the cautery or fascial interposition techniques.

Question 77

Azoospermia is achieved much later with the ligation (and excision) compared to the cautery or fascial interposition techniques.

Answer 77

Waiting at least three months will reduce the number of false-positive samples, thus minimizing the need for repeat laboratory assessment and counseling.

Question 78

According to the 2022 Canadian Urological Association best practice report, when should post-vasectomy testing ideally be conducted?

Answer 78

Post-vasectomy testing should be conducted at three months after vasectomy.

Question 79

What grade does the Canadian Urological Association give to the recommendation of conducting post-vasectomy testing at three months after the procedure?

Answer 79

Grade C.

Question 80

What indicates a successful vasectomy according to the report?

Answer 80

Azoospermia or rare immotile sperm (<100,000 per/ml).

Question 81

After producing one azoospermic sample or one semen sample with rare immotile sperm, what can men do regarding contraceptive measures?

Answer 81

They may abandon contraceptive measures.

Question 82

Whose responsibility is it to communicate the results of a vasectomy to the patient?

Answer 82

It’s the physician’s responsibility, not the laboratory’s.

Question 83

What risk must physicians remind couples about even after an initial successful vasectomy test?

Answer 83

The risk of late failure, approximately 1 in 2000.

Question 84

What percentage of samples have rare non-motile sperm at three months post-vasectomy?

Answer 84

Approximately 20–40%.

Question 85

: If there’s doubt regarding the analysis of a sample, what might physicians want to do?

Answer 85

Contact the laboratory to confirm there was no reporting error and ensure the sample wasn’t incorrectly labeled as “non-motile”.

Question 86

How does the literature view the risk of pregnancy from non-motile sperm at three months post-vasectomy?

Answer 86

The risk of pregnancy is small, perhaps no more than the risk of late pregnancy after two azoospermic semen samples due to spontaneous re-canalization.

Question 87

What should physicians instruct patients to do if any motile sperm or substantial numbers of immotile sperm (>100,000 sperm/ml) are detected?

Answer 87

Inform the patient to continue using other contraceptive measures and request a repeat semen analysis. A repeat vasectomy might be indicated if persistent motile sperm or large numbers of non-motile sperm are found.

Question 88

: Under what conditions is a vasectomy considered a failure according to the recommendation?

Answer 88

Persistence of any number of motile sperm or >100,000 sperm/ml on two semen samples.

Question 89

How is late vasectomy failure usually first identified?

Answer 89

It’s first identified as a pregnancy and later confirmed by semen analysis documenting the presence of motile spermatozoa.

Question 90

What kind of initial visit should be done for a vasectomy consult?

Answer 90

A preoperative interactive consultation should be conducted, preferably in person.

If an in-person consultation is not possible, then preoperative consultation by telephone or electronic communication is an acceptable alternative.

Question 91

What concepts need to be discussed when counseling a patient who wants a vasectomy?

Answer 91

 Vasectomy is intended to be a permanent form of contraception.
 Vasectomy does not produce immediate sterility.
 Following vasectomy, another form of contraception is required until vas occlusion is confirmed by post- vasectomy semen analysis (PVSA).
 Even after vas occlusion is confirmed, vasectomy is not 100% reliable in preventing pregnancy.
 The risk of pregnancy after vasectomy is approximately 1 in 2,000 for men who have post-vasectomy azoospermia or PVSA showing rare non-motile sperm (RNMS).
 Repeat vasectomy is necessary in ≤1% of vasectomies, provided that a technique for vas occlusion known to have a low occlusive failure rate has been used.
 Patients should refrain from ejaculation for approximately one week after vasectomy.
 Options for fertility after vasectomy include vasectomy reversal and sperm retrieval with in vitro fertilization. These options are not always successful, and they may be expensive.
 The rates of surgical complications such as symptomatic hematoma and infection are 1-2%. These rates vary with the surgeon’s experience and the criteria used to diagnose these conditions.
 Chronic scrotal pain associated with negative impact on quality of life occurs after vasectomy in about 1-2% of
men. Few of these men require additional surgery.
 Other permanent and non-permanent alternatives to vasectomy are available.

Question 92

What is the risk of pregnancy after vasectomy?

Answer 92

The risk of pregnancy after vasectomy is approximately 1 in 2,000 for men who have post-vasectomy azoospermia or PVSA showing rare non-motile sperm (RNMS).

Question 93

What is the rate of repeat vasectomy?

Answer 93

Repeat vasectomy is necessary in ≤1% of vasectomies, provided that a technique for vas occlusion known to have a low occlusive failure rate has been used.

Question 94

What are the surgical risks of the procedure?

Answer 94

The rates of surgical complications such as symptomatic hematoma and infection are 1-2%.
-These rates vary with the surgeon’s experience and the criteria used to diagnose these conditions.

Chronic scrotal pain associated with negative impact on quality of life occurs after vasectomy in about 1-2% of
men.
-Few of these men require additional surgery

Question 95

Is vasectomy a risk factor for prostate cancer, coronary heart disease, stroke, hypertension, dementia or
testicular cancer?

Answer 95

Clinicians do not need to routinely discuss prostate cancer, coronary heart disease, stroke, hypertension, dementia or testicular cancer in pre-vasectomy counseling of patients because vasectomy is not a risk factor for these conditions.

Question 96

What prophylactic antimicrobials are necessary for vasectomy?

Answer 96

Prophylactic antimicrobials are not indicated for routine vasectomy unless the patient presents a high risk of infection.

Question 97

What kind of anesthesia should be performed for vasectomy?

Answer 97

Vasectomy should be performed with local anesthesia with or without oral sedation.

If the patient declines local anesthesia or if the surgeon believes that local anesthesia with or without oral sedation will not be adequate for a particular patient, then vasectomy may be performed with intravenous sedation or general anesthesia.

Question 98

How should the isolation of the vas be performed?

Answer 98

Isolation of the vas should be performed using a minimally-invasive vasectomy (MIV) technique such as the no scalpel vasectomy (NSV) technique or other MIV technique.

Question 99

What are the three divisional methods for occlusion of ends of the vas?

Answer 99

The ends of the vas should be occluded by one of three divisional methods:

(1) Mucosal cautery (MC) with fascial interposition (FI) and without ligatures or clips applied on the vas

(2) MC without FI and without ligatures or clips applied on the vas

(3) Open ended vasectomy leaving the testicular end of the vas unoccluded, using MC on the abdominal end and
FI

OR by the non-divisional method of extended electrocautery.

Question 100

The divided ends of the vas may be occluded by:

Answer 100

The divided vas may be occluded by ligatures or clips applied to the ends of the vas, with or without FI and with or without excision of a short segment of the vas, by surgeons whose personal training and/or experience enable them to consistently obtain satisfactory results with such methods.

Question 101

Should you send the excised component of the vas for pathology?

Answer 101

Routine histologic examination of the excised vas segments is not required.

Question 102

When should men use contraception after vasectomy?

Answer 102

Men or their partners should use other contraceptive methods until vasectomy success is confirmed by PVSA.

Question 103

Details of the semen sample for post-vasectomy semen analysis

Answer 103

To evaluate sperm motility, a fresh, uncentrifuged semen sample should be examined within two hours after
ejaculation.

Patients may stop using other methods of contraception when examination of one well-mixed, uncentrifuged, fresh post-vasectomy semen specimen shows azoospermia or only rare non-motile sperm (RNMS or ≤ 100,000 non-motile sperm/mL).

Question 104

When should the post-vasectomy PVSA be done?

Answer 104

8-16 weeks after vasectomy is the appropriate time range for the first PVSA.

The choice of time to do the first PVSA should be left to the judgment of the surgeon.

Question 105

When should vasectomy be considered a failure?

Answer 105

Vasectomy should be considered a failure if any motile sperm are seen on PVSA at six months after vasectomy, in
which case repeat vasectomy should be considered.

Question 106

If ______ sperm persist beyond ____ months after vasectomy, then what should you do?

Answer 106

If > 100,000 non-motile sperm/mL persist beyond 6 months after vasectomy, then trends of serial PVSAs and
clinical judgment should be used to decide whether the vasectomy is a failure and whether repeat vasectomy should be considered.

Question 107

What happens if you see MOTILE sperm on a PVSA?

Answer 107

Vasectomy should be considered a failure if any motile sperm are seen on PVSA at six months after vasectomy, in
which case repeat vasectomy should be considered.